PERMIT TO WORK
PTW #
HOT WORK COLD WORK CONFINED SPACE
Section 1 PERMIT REQUEST (To be filled by the permit requestor)
Work Description:
D.NO:
Start Day Month Year Stop Day Month Year Daily Weekly Remarks
Area Street X
Location
Community Plot Y
Tools & Equipment:
Ladder Mobile Crane Pumps
Hand Tools Telehandler Spanners
Power Tools Excavator Multimeters
Small Machineries Dozer Calibration Meters
Trucks JCB Cleaning Brushes
Compressor Shovel Wipers
Generator HIAB Truck
MST Equip./Oper. Certificates Requested By CP:
RA MSDS Designation:
Task Briefing /Training Ext. Permit/NOC Signature:
Drawing Date:
Section 2 HAZARDS & CONTROL MEASURES (To be filled by the Construction Manager or HSE Manager (AA)
Hazards Control Measures / Precautions PPE:
Unauthorized persons Flying objects Valid Permit or NOC Adequate ventilation Safety Helmet
PTW/certificates Lack of Oxygen Method Statement available Shoring or Sloping Hand Gloves
Inappropriate PPE Dust Risk Assessment available Start Checklist Eye Protection
Unprotected edge Contaminated soil Drawings available Fall Protection Coverall
Excavation Edge collapse Virus Pre-Task Briefing done Barriers / Protection Face Shield
Fire Heat Stress Supervision available on site Hi Vest Jacket
Fall from Height Work at Height Standard PPEs worn Safety Shoes
damaged tools Oil leakage Barricading of Hazards in place Ear Protection
Access/Egress Existing Structures Safety Signs & Signals in place Safety Harness
Mechanical Failure Toxic gases Safe Access / Egress in place Dust Mask
Suspended Load High Noise level; Gas Monitoring Full body harness
Load failure Lack of lighting Trial Pit done Leather Apron
Method Statement Risk Assessment External Permit Equip./Oper. Certificates
Attachments:
Job Safety Analysis Drawings NOC Insp. & Test Plans
Section 3 PERMIT REVIEWER
I have personally checked the work required and proposed safety control measures / precautions mentioned in Section 2 by Authorizing Authority. I have discussed this measures with the Job
Performing / Foreman.
Reviewed By: Designation: Safety Date: Sign:
Section 4 PERMIT ISSUING
I am authorizing this Permit and handed the site safe and proposing above mentioned Control Measures /Precautions to be in place during the works.
Authorizing By: Designation: PM Date: Sign:
Section 5 PERMIT RECIEVER
I will abide the condition/precaution mentioned in this permit Section 2, and ensure required measures in place prior and during work. I will conduct the pre-task briefing with the group prior to start
the work.
Received By: Designation: Engr. Date: Sign:
Section 6 PERMIT Closing
I am closing this Permit and handed the site safe and confirming the above works are completed.
Confirmed By: Designation: Engr. Date: Sign:
Section 7 THIS PERMIT IS CANCELLED OR CLOSED OUT
The work is completed, site cleared, tool and equipment removed, and area is safe for Original works and WP is cancelled
Inspected Accepted
Incomplete Complete Name Sign Date Time
Yes No Yes No
HSE Officer
Authorizing By: Designation: Safety / PM Date: Sign:
PERMIT TO WORK
DAILY REVALIDATION (if task continues)
Filled by Competant Person / Foreman Filled by HSE OFFICER
Date Time Task Briefing
Done
Name Signature Name Signature HSE Officer Signature
GAS TEST REQUIREMENT (To be filled by the Authorized Gas Tester)
Date Time Oxygen (19.5-22.5 %) Combustible (<5%)LEL H2S (<10 PPM) Name Signature
Continuous gas test monitoring required Yes No Name: Date & Time Sign:
DAILY GAS TEST REVALIDATION (if task continues)
Date Time Oxygen (19.5-22.5 %) Combustible (<5%)LEL H2S (<10 PPM) Name Signature
CONFINE SPACE (IN & OUT Log Sheet)
Location Entrants Designation Time IN Sign Time OUT Sign
